| NPI | 1619753092 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 11842) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: GA 11842) |
| Enumeration Date | 2023-09-01 |
| Last Update Date | 2023-09-01 |